Introduction

This quality standard covers the prevention, diagnosis and management of delirium in adults (18 years and over) in hospital or long-term care settings. For more information see the topic overview.

Why this quality standard is needed

Delirium (sometimes called 'acute confusional state') is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1–2 days. It is a serious condition that may be associated with poor outcomes. However, it can be prevented and symptoms treated if dealt with urgently.

Delirium can be hyperactive or hypoactive, but some people show signs of both (known as mixed delirium). People with hyperactive delirium have heightened arousal and can be restless, agitated and aggressive. People with hypoactive delirium become withdrawn, quiet and sleepy. Hypoactive and mixed delirium can be more difficult to recognise.

It can be difficult to distinguish between delirium and dementia because symptoms overlap, and some people may have both conditions. Dementia tends to develop slowly, whereas delirium is characterised by sudden changes. Dementia is generally a chronic, progressive disease for which there is no cure. Delirium is a potentially reversible condition if the causes are identified and they are treatable. If clinical uncertainty exists over the diagnosis, initial management should be for delirium.

Older people, and people with cognitive impairment, dementia, severe illness or a hip fracture, are more at risk of delirium. About 20–30% of people on medical wards in hospital have delirium, and between 10% and 50% of people who have surgery develop delirium, with considerable variation across different types of surgery and settings. In long-term care settings, the prevalence of delirium is under 20%. The prevalence of delirium tends to rise with increasing age, but reporting of delirium is poor in the UK, indicating that awareness and reporting procedures need to be improved.

The quality standard is expected to contribute to improvements in the following outcomes:

  • length of hospital stay

  • detection of delirium

  • incidence of delirium

  • falls in hospital

  • mortality

  • adults' experience of hospital care

  • carer involvement in healthcare.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 The Adult Social Care Outcomes Framework 2014–15

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life (NHSOF 2**)

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 1000 population

Outcome measure

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services (NHSOF 3.6i*)

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction of carers with social services

Outcome measure

Carers feel that they are respected as equal partners throughout the care processes

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

Aligning across the health and care system

* Indicator shared with NHS Outcomes Framework (NHSOF)

** Indicator complementary with NHS Outcomes Framework (NHSOF)

Table 2 NHS Outcomes Framework 2014–15

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults*

3 Helping people to recover from episodes of ill health or following injury

Improvement area

Helping older people to recover their independence after illness or injury

3.6i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services (ASCOF 2B**)

4 Ensuring that people have a positive experience of care

Overarching indicator

4b Patient experience of hospital care

Improvement area

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to in-patients' personal needs

Alignment across the health and social care system

* Indicator complementary with Public Health Outcomes Framework (PHOF)

** Indicator shared with Adult Social Care Outcomes Framework (ASCOF)

Table 3 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable*

Alignment across the health and social care system

* Indicator complementary with NHS Outcomes Framework (NHSOF)

Coordinated services

The quality standard for delirium specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to adults with delirium.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality delirium service are listed in Related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners involved in assessing, caring for and treating adults with delirium should have sufficient and appropriate training and competencies to detect and manage delirium in order to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with delirium. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the assessment of delirium and the decision-making process about investigations, treatment and care.